HomeMy WebLinkAboutMortgage_Grimes �_ . STATEMENT
EDUC IO MORTGAGE S ED ALUAT INDEBTEDNESS County Township Year
kir eii) FOR DEDUCTION FROM ASSESSED VALUATION I
State Form 43709(R13/10-15)
Presrnbed by Department of Local Government Finance
INSTRUCTIONS: File Mark
vt
To be filed in person or by mail. J U 0 fi=• AP.
Filing Dates 1) Real Property.Must be completed and dated in the calendar year for which the deduction is sought
Must be filed orpostrnadced with the County Auditor or County Recorder of the county where the properly is ❑ •u4, a - r
located on or bef ore January 5 of the immediately succeeding calendar year. 1. • r FefirlFt;. Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the yglLt„N r AUDITOR
where the property is located during the Mv/vs(12)months before March 31 of each year the deduction r 3btll�rhhft
See reverse side for additional instructions and qualifications.
Applicant I;w conhaa res✓ 'on°reverse ' ) _'�(iti
Taxing District number/legal description l�1''W, _I_ri.Q�/j Record number Page number
- cam - o- DOD, 386- r i 6. •16 55
Assessed value at of real nt y e r as of assessment!Contract rent year unpaid as of date application/Contact indebtedness unpaid as of Is the applicant e the sner
assessment date,arced year assessment loth,current year data of applicalgn legal or equitable owner?
121 abo ❑ Yes 0 N
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below. Is the property in question:Annually Assessed
❑ Real Property ❑ AnnualyAssessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller nel.
Address of mortgagee or contract serer(number and street city, and ZIP code)
Name of assignee or other owner or holder of mortgage - I
1
Drawer NO _
Address of assignee(number and street city,Mate,and ZIP code) l/y� [JJ/�, l Lam,
Does applicant own properly in any If yes,what county? What Taxing District? Has U,, Card NO./ ` ^�-`v —
oUrsana? ❑Yes 0 N aanirter _
A person is not entitled to this deduction unless the person has a balance on the person's mori::
recorder's office(including any home equity line of credit that is recorded in the county recorders bmce)mat rs the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of.
20 20 20_ 20 20_ 20 20
Signature of County Auditor County - Date(month,day,year)
I/We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner)contract�bnuay/der of the aforementioned property on date application is fled.
Sgraatgfry`i
Date(month,day,Yew
Fug resident address of applicant(number and city,slate,and LP code)
52/ S. 9fi% re . 1/41d6s it,if.. '17639
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street dry,state,and ZIP code)
I
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.